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Report of the Study Group of the World Health Organization

The Study Group on Treatment and Care of Drug Addicts, of the World Health Organization, met in Geneva from 19 to 24 November 1956, and made a report1 which was noted by the Executive Board of the World Health Organization at its twentieth session held in Geneva from 27 to 28 May 1957 (resolution E/B.20.R/14, document E/B.20/MIN/2).

The main features are as follows:

The task set the Study Group was to consider the scientific knowledge and clinical experience on the treatment and care of drug addicts. The goal was the determination of principles which might be applied to the management of addicts with different etiology, and pathology and in various cultural surroundings.

In order to achieve practical results, it was agreed that little of additional value would be accomplished in discussing definitions of addiction. It is recognized that there are many and widely divergent views on what constitutes an addiction; and the point at which drug use becomes drug addiction depends to quite an extent on the orientation of the observer - that is to say, whether he looks at it from, for instance, the pharmacological, psychological, forensic, social, political or moral point of view. While physicians and scientists are mainly concerned with those characteristics of drug addiction which affect the individual's health and welfare, society is less interested in these effects unless they interfere with social productivity or have an adverse effect on other members of society resulting, for instance, in antisocial acts. Therefore, the Study Group accepted the public health concept according to which an addict is a person who habitually and compulsively uses any narcotic drug so as directly to endanger his own or others' health, safety, or welfare.

Because of the many kinds of drugs used and abused, there was need for a delimitation of the scope of drugs for inclusion in this study to opium, opium alkaloids and substances derived therefrom, synthetic substances with morphine-like characteristics, and cannabis substances.

While recognizing that prevention is an important preliminary aspect of care and treatment, it was agreed that the consideration of prevention be confined to the problem of re-addiction (relapse) of addicts who are undergoing or have undergone treatment.

The Group wished to emphasize very strongly that the treatment of drug addicts is a medical problem, and that drug addicts are patients.

It is apparently not possible, the report states, to describe the addict as a well-defined type. Although much could be and has been written about the etiology and pathology of drug addiction, unfortunately very little has been proved to have a firm scientific basis. of greatest practical value at present in connexion with the treatment and care of the addicts is perhaps their classification according to amenability to treatment.

1 Wld. Hlth. Org. techn. Rep. Ser., 1957.

Fortunately, a great number of addicts would come under the category of easy amenability to treatment. This group would comprise those persons who are exposed to some more or less accidental stress such as exhaustion, hunger and poverty, and would predominate in countries where the drugs used are relatively easily available and the cost not prohibitive. Here mass methods of treatment may be highly successful. In many cases, good results may fairly easily be obtained where the addiction is mainly due to social, environmental or cultural factors. Among these may be included the historical and cultural acceptance of the use of certain drugs by some segments of the population in a few countries. It has been observed in at least one country that forceful measures against the widespread use of drugs including propaganda and education have in a short space of time changed the general attitude of tolerance to one of opprobrium. In other countries, where the use of drugs is less general, there may be groups or gangs - frequently of an asocial or antisocial character - where drug-taking or addiction is a prerequisite of full participation. Many such addicts will be easily amenable to treatment once removed from this sub-cultural influence.

The therapeutic problem is also often not too difficult where the drug addiction is the result of some episode of an illness, physical or psychological in origin, and where the main motive for taking drugs disappears once the conditioning illness has passed - for example, in the case of very painful diseases and manic depressive illness. In such patients, the addiction is not due to a primary personality disorder. It is not too difficult to motivate the patient towards giving up the drug, even if the withdrawal creates physical or mental hardship, as soon as the additional motive of pain or deep depression has disappeared as a consequence of, or even without, treatment.

The group of addicts most difficult to treat, numerically smaller than the above, is composed of those who suffer from a basically pathological character structure. In these people, the more the drugs are used to solve their deep-rooted personality problems, the more malignant the addiction. Here, intensive treatment of a psychotherapeutic nature is necessary, and must be based in each case on an analysis of the factors leading up to drug addiction. Among the causative personality factors are frequently found immaturity of character development, a desire to live only in the present, a narcissistic attitude, or a destructive - even a self-destructive - tendency. The lack of a sense of meaning in life and the desire to escape from reality characterize many of this group, who often show a low capacity for dealing with frustration, anxiety and stress. Among the underlying early causes of these symptoms are found the following factors:

Emotional deprivation, resulting from broken homes or lack of interest shown by parents in their children;

Over-indulgence and lack of disciplinary training36

Difficulty for the child in identifying with a parental figure and forming a proper ideal-for example, in the case of broken homes-or where parents are seldom at home, or their relationship is weak;

An unrealistic middle-class attitude oriented towards standards differing from the sub-culture to which the child belongs;

Distrust of authorities, arising from the above.

Thus, to sum up, these drug addicts may frequently be found to suffer from poor ego and superego development, which also explains a certain tendency towards unreliability and untrustworthiness which can be observed amongst them.

Viewed according to amenability to treatment, drug addiction appears to have a much less pessimistic prognosis than is generally believed when only the last-mentioned group is focused into the centre of attention. It should be remembered, however, that dynamic transitions may occur between the above-mentioned groups.

The basic requirement for effective treatment is that there must be an effective limitation in the supply of drugs. In co-ordination with the United Nations organs concerned with the international control of narcotic drugs, this problem is being dealt with most vigorously in many countries, but it is pointed out that one country may be hindered in securing this limitation if neighbouring countries have not adopted a similar policy.

The legal circumstances involved are of great importance for the success of treatment programmes. In a number of countries, provisions exist but are little used in practice. While a few mature patients should be allowed to submit voluntarily to treatment, most addicts will require some degree of coercion- preferably some kind of civil commitment to medical treatment.

In certain societies and countries, the addict may by law be classed as a criminal. In such instances he should, if possible, have all the benefits of adequate medical care as outlined later.

For an ideal programme to be carried out, adequate facilities for treatment are, of course, essential. It is realized that this may not be possible in all countries; nevertheless, the general principles of treatment can be followed.

It cannot be too strongly emphasized that the first principle of the treatment of drug addicts is that they should be looked upon as patients-that is to say, treated medically and not punitively-and emphasis should be placed upon their individual personality. The main characteristic of treatment will therefore be its psychotherapeutic nature, and it will not be fundamentally different from that used in the psychotherapeutic management of other personality problems. Such treatment should aim at giving the patient more insight into his problems, some understanding of the unrealistic character of his neurotic fears and wishes, and a better judgment of situations, thus enabling him better to respond to the unavoidable stress of life.

Although it will frequently be necessary to resort to coercion before the patient can be made to undergo treatment, as far as possible he should be allowed to make-or to feel he has made-a free decision, so that, from the beginning, some degree of co-operation may be obtained, and treatment may be based on a sense of trust. This will be partly dependent, of course, on the prognostic category of the patient, the attitude of the surrounding society- which may assist in the motivation of the patient to obtain treatment-the propaganda value of results already obtained and, of course, the attitude and judgment of the physician.

There was complete agreement that the goal of treatment of the addict is to assist him to achieve a feeling of relative well-being and satisfaction and good interpersonal adjustment without drugs. It should be very clearly understood that the maintenance of drug addiction is not treatment. Nevertheless, under certain circumstances, complete withdrawal of the drug of addiction might be deferred.

There are well-recognized obvious medical conditions, such as severe chronic or terminal illnesses, where continued administration of drugs is indicated. In addition, experience with the problems of addiction in several countries, and newer knowledge of the psychology of addiction, lead the medical profession to believe that in exceptional cases it is within the limits of good medical practice to administer drugs over continuing periods of time. In any case, the physician, recognizing the presence of addiction, should not embark upon continuation of the drug of addiction without having adequate previous consultation and periodic review with competent medical authority.

Comprehensive medical treatment of the drug addict should be total-that is, somatic, psychological and social rehabilitation of the individual. The treatment consists of three phases-the preparatory phase, withdrawal, and continued treatment-all of which should be part of a continuing process which may have to extend over several years. Experience has shown that, when the addict continues under the care of one physician and his team of workers, it is much easier to check his progress or his relapses than if he comes under the supervision of a variety of people working without relation to one another.

The preparatory phase of treatment should include an assessment of the drug used, the degree and duration of addiction, and the addict's personality structure and problems. At this stage, a plan of treatment should be outlined and discussed with the patient in order to allay his anxiety, and in the hope of promoting his motivation to recovery.

As withdrawal is often painful and may cause misery and frustration, it must be very skilfully carried out. Whatever the method of treatment, the first responsibility of the physician is to carry through withdrawal as quickly and humanely as possible. On the other hand, undue emphasis and concern over methodology and a lack of understanding of the physiology of the withdrawal syndrome may distort this phase out of proportion to its proper value. One should not confuse withdrawal with the total treatment of the patient. Indeed, one may say that the process of withdrawal is self-limiting, providing that the drug is withdrawn and the treatment not so strenuous as to affect the patient adversely.

Since cannabis substances do not produce physical dependence, they can be withdrawn abruptly without the appearance of physical symptoms, and hence without somatic damage for the addicted individual. Therefore, the following comments relate only to opium, opiates, and morphine-like synthetic substances.

There are two categories of withdrawal: (1) the gradual withdrawal of narcotics with varying degrees of rapidity, and (2) the abrupt withdrawal of narcotics.

The methods of gradual withdrawal can be subdivided into:

The prolonged gradual withdrawal over a period of weeks or months, using the actual drug of addiction. Supportive therapy may include substances such as barbiturates, bromides, scopolamine, hyoscyamus, atropine and, more recently, chlorpromazine, reserpine and meprobamate;

The rapid withdrawal of narcotics which is usually accomplished in seven to fourteen days. Supplemental therapy may include the above 1 ( a) substances;

The substitution for the drug of addiction of other narcotics, the withdrawal of which entails less severe symptoms than the withdrawal of the drug of original addiction.

The methods of abrupt withdrawal include:

Abrupt cessation of the administration of narcotics or any other drug. Supportive therapy, such as intravenous fluids, cardiovascular stimulants, etc., may be used in cases of severe collapse besides other therapeutic measures to provide relief of symptoms;

As above in 2 ( a), except that other non-narcotic substances may be used, such as barbiturates, calcium compounds, scopolamine, hyoscyamus, chlorpromazine, reserpine, and meprobamate, the common feature of which is to mask the symptoms and signs of withdrawal;

As above in 2 ( a), except that electroshock or insulin shock is periodically induced.

Of the methods of withdrawal of opium, opiates or morphine-like synthetic drugs, the methadone substitution technique was considered by the majority of the Group to be the most effective, simple and easy to carry out. The patient is given, depending on the severity of withdrawal signs, up to 20 mg of methadone (either orally or hypodermically) three times a day. After the first day, the methadone is rapidly reduced to zero over a period of three to ten days. This method requires considerable experience in the evaluation of withdrawal signs and symptoms, and should be used with caution.2

With reference to the so-called masking treatment, such as barbiturates, chlorpromazine, etc. (see above) which often make the withdrawal unnecessarily dangerous,3 particularly so in view of the relatively low risks involved in the methadone substitution technique-although these drugs may be useful after withdrawal from opiates has been completed-the Group also recognizes that there are drugs on the market said to minimize the withdrawal symptoms in a miraculous way. For the cure of addicts, patented treatments and medicines have also been brought out, which may include a variety of drugs of no or negligible specific therapeutic value. These methods have not been substantiated by carefully controlled scientific clinical experiment.

During or shortly after the withdrawal period, efforts should be instituted to correct any remediable somatic diseases or abnormalities. It is possible that the institution of such corrective procedures may properly delay the complete withdrawal until a more appropriate time (e.g., severe cardiac distress, bronchiogenic asthma, etc.).

As soon as possible, the continued treatment stage should be started. This phase is the most time-consuming, at times frustrating, and yet the most important. The aim of continued treatment is to rehabilitate the addict to a degree which makes it possible for him to withstand the normal wear and tear of life without having recourse to the use of drugs.

In many patients, the sudden release from drug enslavement leads to over-confidence on the one hand, or may be so discouraging and unrewarding on the other that, if emotional support is not provided by the physician, these patients will fail to continue in therapy. Experience has shown that during this critical period, which may in some cases extend over two to three years, there is a high rate of relapse. During this stage, it is most important that the individual be given strengthening and moral support from his physician, from his home, friends, work, and from the community, including religious institutions.

The tendency to discontinue treatment makes it necessary that measures be taken which, at the same time, allow the physician to exercise the necessary amount of control over the patient while allowing him to acquire an increasing degree of responsibility for his own life.

It was agreed that the most effective method of assuring this prolonged period of treatment is through some form of civil commitment to medical care, although it was realized that methods would vary from country to country. Such commitment should continue until the patient is discharged by competent medical authority. This period of enforced treatment could be carried out both in and out of institutions in the same manner as with other psychiatric disorders. There should also be provision for those addicts who can voluntarily co-operate with a long-term programme without enforced commitment.

It would seem advisable to provide a graded series of environmental conditions for treatment. The determination of the degree of security required in any given case should be left to the judgment of the physician. This grading process would extend from the maximum security of locked wards down through open wards, "half-way house" (controlled or sheltered environment) in the community, and so to a controlled environment in the home where, with the help of his private doctor or community public health officer, the former addict may finally return to self-supervision. The placing of the addict in any given step in this process would depend in some degree on the evaluation of several factors, such as his personality development, family identification, degree and extent of drug use, and certain community attitudes. The placement should not depend only on his taking or not taking drugs, but should take into account the whole situation. It should be made clear that no part of the above process implies penological coercion.

Since the bulk of the time of continued treatment will often be spent outside institutions, every effort should be made to enlist all community agencies, such as social service, family welfare, mental health clinics, vocational rehabilitation, employment services, etc., to provide and assist in community adjustment for the returning addict. It is in the community that addiction starts, and it is in the community that the final phase of adjustment and adaptation should occur. In some cases, group psychotherapy for the addict's family will be found to be necessary.

For certain addicts as mentioned above - namely, those with proper motivation - there should be provision for complete treatment outside as well as inside institutions. Newer knowledge of the psychology of human behaviour, experience gained by physicians in treating addicts, and parallel experience with the treatment of other psychiatric disorders, have led the Group to agree that traditional concepts of treating the first and second phases of addiction in closed institutions only should not necessarily be followed in all cases. There should be provision, legal and otherwise, for the treatment in the home, physician's office, or out-patients' clinic of properly selected cases, so judged by competent medical authority.

There are many serious gaps in present-day knowledge; there is, for instance, a need for:

The determination of the prevalence and incidence of drug addiction in the various countries, in connexion with which it would be of value to know the kinds of drugs used (why and where); and the reasons for the cyclic fluctuations in drug abuse.4

The development of more precise diagnostic tools - e.g., simple field laboratory techniques for the detection of drugs in the urine.

Longitudinal life studies of addicts, to determine among many others such items as more specific and deep-going descriptive biographical data; origin and development of addiction; replacement or addiction of different drugs in the course of addiction or replacement of addiction by another mental disorder; relation between personality structure and choice of drugs; effectiveness of various methods of treatment.

All these relate in general to the epidemiology of drug addiction. However, there is also a need for more information in the realm of sociology, such as:

The influence of social attitudes on the development of different kinds of addicts and addiction.

The effect of families and immediate social groups on the development and course of addiction. The recent developments in psycho-pharmacology offer the possibilities of new vistas in a more precise understanding of the effects of drugs from a neurophysiological standpoint. The long-sought-for drug which will relieve physical pain without the danger of addiction may be developed from this work.

An annex to the report contains background information related to the subject of the Study Group.